Provider Demographics
NPI:1780657213
Name:LERTORA, JOHN MARK (OD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARK
Last Name:LERTORA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 TUNXIS AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BLOOMFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06002-2034
Mailing Address - Country:US
Mailing Address - Phone:860-243-2508
Mailing Address - Fax:860-243-9332
Practice Address - Street 1:38 TUNXIS AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002-2034
Practice Address - Country:US
Practice Address - Phone:860-243-2508
Practice Address - Fax:860-243-9332
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002069152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004065280Medicaid
CT0232970001Medicare NSC
CTT23511Medicare UPIN
CT410000378Medicare PIN